A man died after choking on a sausage his support worker failed to cut up properly, a new report has revealed.
Deputy Health and Disability Commissioner Rose Wall has found IDEA Services, and two support workers, failed in their care of the resident.
Wall said in her report the incident happened in 2018 and involved a man, referred to as Mr A, who had cerebral palsy and an intellectual disability.
She said Mr A's support plans identified him as being at risk of choking.
"He was one of three residents living at the house who had a known choking risk. Staff were aware of the risk, and IDEA Services said that the risk of choking was noted prominently on the house menu plan and on the front of the personal daily information books.
"Mr A's risk of choking was also noted in his medication folder, his personal support information (PSI), and Alerts & Crisis (A&C) information."
Wall said that on the day of the incident, Mr A left the table during dinner and was found unresponsive by one of the support workers — Ms B.
"Sadly, it was found that Mr A had suffered a fatal brain injury owing to a lack of oxygen. Mr A died two days later, shortly after being taken off life support. The coroner determined that this was a preventable death and referred the case to HDC," Wall's report said.
The investigation found that Ms B had not cut up the man's sausage despite being aware of his choking risk and the expectations around meal preparation. She was also not in the room while he was eating.
It also found Ms B did not attempt to clear Mr A's airway prior to commencing CPR despite having received training.
Another support worker, Ms C, had left early to try and finish a time-card training module, Wall noted in her report. This had left the team short-staffed.
Wall said IDEA Services gave a verbal and written apology to Mr A's family, while both Ms B and Ms C gave the organisation an apology to pass on.
She noted both Ms B and Ms C no longer work for IDEA services or as support workers. She described them as "extremely remorseful".
The Deputy Health and Disability Commissioner recommended Mr A's case be used as a case study in staff training as "a reminder of the significance of choking".
Wall also said there should be a "documented and clearly communicated expectation staff do not leave any shift early without the express permission of their manager".
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